ABSTRACT
BACKGROUND AND OBJECTIVES: Orofacial pain is as-sociated to soft and mineralized oral cavity and facial tissues. In dentistry, it may have or not odontogenic origin. Temporo-mandibular disorder (TMD) is the most common musculo-skeletal orofacial pain and presents characteristic symptoms such as masticatory muscles pain, jaw movement limitation, joint noises, earache and tinnitus. Tinnitus is a term describ-ing the perception of sound by human ears in the absence of external sounds and causes discomfort impairing quality of life. It may be a symptom indicating TMD especially when other symptoms are present, such as facial muscles pain. Due to etiologic variability, there are several therapeutic modali-ties, including acupuncture. his study aimed at reporting a case of a patient with orofacial pain and tinnitus treated with acupuncture and the results after treatment.
CASE REPORT:Female patient, 32 years old, came to the Acu-puncture Clinic of the School of Dentistry of Piracicaba (FOP/ UNICAMP) complaining of facial muscle pain and pricking at the same side, acute right ear tinnitus, already with diagnosis of left ear hearing loss and with sleep disorders and stress. Patient was treated according to her energetic unbalance with 6 sessions of traditional acupuncture, for one week, lasting 20 minutes. To evaluate orofacial pain and tinnitus intensity, the visual analog scale (VAS) was used and was called initial VAS (pre-treatment) and inal VAS (post-treatment). After the second session there has been improvement in orofacial pain and tinnitus symptoms. After the sixth session tinnitus had resolved.
CONCLUSION: Acupuncture has induced muscle relaxation with beneits for masticatory and middle ear (tensor tympani) muscles, as well as levator palate muscle decreasing orofacial pain and tinnitus intensity.
Keywords:Acupuncture therapy, Meridians, Orofacial pain, Tinnitus.
Acupuncture to manage orofacial pain and tinnitus. Case report*
Acupuntura no manuseio da dor orofacial e do tinido. Relato de caso
Rosario Martha De La Torre Vera1, Cássia Maria Grillo1, Maria Lucia B.Fortinguerra1, María da Luz R. Sousa1, Fausto Berzin1
*Received from the School of Dentistry. Piracicaba, SP.
1. State University of Campinas, School of Dentistry. Piracicaba, SP, Brazil.
Submitted in January 02, 2013. Accepted for publication in June 06, 2013. Conlict of interests: None.
Correspondence to:
Rosario Martha De La Torre Vera Av. Limeira, 901 – Bairro Areão 13414-903, Piracicaba, SP. E-mail: ccchary@hotmail.com
RESUMO
JUSTIFICATIVA E OBJETIVOS: Dor orofacial é toda dor associada a tecidos moles e mineralizados da cavidade oral e da face. Na odontologia, podem ser de origem odontogêni-ca e não odontogêniodontogêni-ca. A disfunção temporomandibular (DTM) é a dor orofacial musculoesquelética mais comum, apresenta sintomas característicos como dor nos músculos mastigatórios, limitação dos movimentos mandibulares, ruí-dos articulares, otalgia, tinido. Tinido (zumbido) é um ter-mo que descreve a percepção de som no ouvido humano na ausência de som externo, causa de incômodo com prejuízo na qualidade de vida. Pode ser um sintoma indicativo de uma DTM principalmente quando estão presentes outros sintomas característicos da disfunção como dor nos múscu-los da face. Devido à variabilidade etiológica, encontram-se várias modalidades terapêuticas, incluindo a acupuntura. O objetivo deste estudo foi relatar o caso de uma paciente com dor orofacial e tinido tratada com acupuntura e seus resulta-dos após o tratamento.
RELATO DO CASO: Paciente do sexo feminino, 32 anos, compareceu a Clínica de Acupuntura da Faculdade de Odon-tologia de Piracicaba (FOP/UNICAMP), com queixa de dor muscular na face e formigamento do mesmo lado, tinido agudo no ouvido direito, já com diagnóstico de surdez do ouvido esquerdo e apresentando distúrbios do sono e estresse. Foi tratada de acordo com seu desequilíbrio energético, em seis sessões de acupuntura tradicional, uma por semana, com duração de 20 minutos. Para avaliar a intensidade da dor oro-facial e do tinido, utilizou-se a escala analógica visual (EAV), denominada EAV inicial (pré-tratamento) e EAV inal (pós-tratamento). Após a segunda sessão, observou-se melhora nos sintomas da dor orofacial e do tinido, que deixou de se mani-festar após a sexta sessão.
CONCLUSÃO: Acupuntura propiciou o relaxamento da musculatura com benefícios para os músculos da mastigação e da musculatura da orelha média (tensor do tímpano), bem como do músculo elevador do palato, reduzindo a intensidade da dor orofacial e do tinido.
Descritores: Dor orofacial, Meridianos, Terapia por acupun-tura, Zumbido.
INTRODUCTION
(bones and teeth) of oral cavity and face. It may be referred to head and/or neck or it may be associated to other pathologies (cervical pain, primary headaches and rheumatic diseases)1. In dentistry, most frequent causes of orofacial pain are odon-togenic, related to dental tissues and their supporting struc-tures (more severe), and non odontogenic, associated to mus-cles, joints and nerves (neuropathic pains)2.
Musculoskeletal orofacial pain has become known in Brazil among laypeople, patients and health professionals as Tem-poromandibular Joint Disorder (TMD)3. TMD is a term deining diferent clinical problems involving muscles of the head, face, mouth, neck and other related structures4.
Common TMD signs and symptoms are: masticatory muscles pain, temporomandibular joint pain, headache, joint move-ments limitation, sensation of hear loss, ear pain and tinnitus5. Tinnitus (or buzz) is a term to describe sound perception by human ear in the absence of external sound6, and may be as-sociated to depressive psychological emotional problems6,7. Tinnitus may also be caused by anatomic abnormalities, but sometimes no etiological structural defect can be found8. he prevalence of tinnitus in people with normal hearing is 26.6%, which increases to 35.1% in people with hearing im-pairment6. Its incidence is not related to age or gender9. Tin-nitus may be classiied in: para-auditory (perceptible) with vascular or muscular origin, and subjective tinnitus of neuro-sensory origin10.
Tinnitus may be an ENT symptom indicating TMD, espe-cially when there are also other signs and symptoms charac-terizing the disorder, such as masticatory muscles pain11. From people with tinnitus, approximately 20% have signii-cant discomfort that impairs their quality of life12. Its treat-ment is a major challenge and there are several therapeutic modalities to eliminate or, in most cases, attenuate tinnitus, such as Tinnitus Retraining herapy, auditory prostheses, electrical stimulation with cochlear implants, biofeedback and psychotherapy13.
Due to symptoms subjectivity and etiological variability, treatment should be tailored to obtain the best results. So, acupuncture may be an additional therapeutic resource to treat tinnitus, because it is a tailored therapeutic practice with holistic view13.
Acupuncture is one of the pillars of the Traditional Chinese Medicine (TCM), developed as from the observation of na-ture phenomena, a system presenting human body as a whole and as part of nature14, based on the stimulation with needles of speciic points deined in the human anatomy13.
Acupuncture for the treatment of tinnitus is similar to its use to relieve pain, because both conditions produce unpleasant emotional and sensory experiences15. In light of the above, this study aimed at evaluating the therapeutic efect of acu-puncture to manage orofacial pain and tinnitus.
CASE REPORT
Female patient, 32 years old, 60 kg and 1.69 m height, who looked for the Acupuncture Clinic of the School of Dentistry,
Piracicaba (FOP/UNICAMP), complaining of facial muscle pain and pricking to the same side, acute right ear tinnitus, already with diagnosis of left ear deafness and with sleep dis-orders and stress.
At face palpation on the side of the referred pain, patient informed that pain would improve when the site was com-pressed (indicative of deiciency according to TCM); facial and cervical muscles were tensioned.
By observing the tongue (Figure 1), procedure to help diag-nosis since tongue in TCM is a microsystem with representa-tion of organs and viscerae16, it was observed the presence of teeth marks on the sides, tremor, thin and white coat, edema and red tip.
K LI – SI - B
G
B SP S
L
LU H - LU
Figure 1 – Scheme of affected tongue zones – Liver (L), Gall Blad-der (GB) and Heart (H).
Patient’s energetic imbalance was identiied through eight principles, being Yin, Cold, Empty, Internal. To select acu-puncture treatment points, the afected meridian and painful face areas were taken into consideration17 and the following points were chosen:
Triple burner meridian (TB)
TB17 (Yifeng), TB18 (Qimai), TB19 (Luxi), TB20 (Jiaosun), TB21 (Ermen), TB22 (Heliao), TB23 (Sishukong).
TB meridian, among other functions, acts on the circulation of the energetic low (Qi mobilization). It is related to the mental aspect for being related to the pericardial meridian (CS), acting as an articulator in the psychic level, in the emo-tional balance between personal relations and those aimed at oneself18.
Small intestin meridian (SI) SI17 (Tianrong), ID18 (Quanliao)
In psychological terms, SI meridian inluences mental lucid-ity and helps decision making, in the sense of knowing the best choice18.
Heart meridian (H)
H7 (Shenmen) – is the most important heart meridian point and its primary action is to calm the mind, being indicated to treat insomnia, anxiety poor memory and others18.
ST36 (Zusanli) – point which balances body energy and strengthens defenses against external pathogenic factors18. Patient was submitted to six sessions of traditional acupunc-ture (Figure 2), once a week, lasting 20 minutes with Huan Qiu (Suzhou Huanqiu Acupuncture Medical Appliance Co. Ltd.) disposable and sterilized needles, individually packed, sizes 0.25 x 25 mm (for facial insertion) and 0.25 x 30 mm (for head, wrist and leg insertion). Skin was cleaned with cot-ton soaked in 70o alcohol. Needles were unilaterally inserted, to the right (side afected by facial pain and tinnitus), until Deqi was obtained, and were not manipulated19.
here has been improvement after the second session, facial and cervical muscles were relaxed and patient reported de-creased tinnitus, which gradually improved after each acu-puncture session, disappearing in the last session (Figure 3). he same scale (VAS) was used to evaluate orofacial pain, where 0 (zero) means no pain and 10 (ten) maximum pain, called initial VAS (before treatment) and inal VAS (after treatment).
Similarly, to evaluate tinnitus intensity, VAS was adapted for tinnitus, where zero means no tinnitus and 10 maximum tin-nitus, called initial VAS (before treatment) and inal VAS (af-ter treatment).
Percentages obtained represented the diference between ini-tial and inal VAS.
Since this is a trial with human beings, it was carried out ac-cording to ethical criteria and to the standards required by the Declaration of Helsinki from 1975. his study was approved by the Research Ethics Committee, School of Dentistry, Pi-racicaba/UNICAMP (099/2008) and was only started after the signature of the Free and Informed Consent Term (FICT).
DISCUSSION
According to the literature20, some TMD signs and symptoms are common among the population, such as in this case, be-ing that the psychological factor has contributed by generat-ing stress, which increases muscle activity, causes fatigue and spasm5. TCM encompasses the holistic concept, where the human body is seen as a whole and all its parts are connected to one another and to the external medium21. Using acupunc-ture, we try to reach physical and emotional balance, provid-ing health recovery.
Using Triple Burner (TB) meridian points, one considers its external and internal pathway, traveling through the auricular region of the inner and outer ear, and joining through its internal pathway the circulation-sex meridian (CS), with the stomach meridian (SM) and the gall bladder meridian (GB)22.
Figure 2 – Points applied around the ear.
Figure 3 – Improved orofacial pain and tinnitus intensity during acu-puncture treatment.
Pain
Tinnitus
Acupuncture Sessions
First Second Third Fourth Fifth Sixty 120%
100%
80%
60%
40%
20%
0%
% of impr
he stomach meridian crosses the face in its internal pathway (being indicated to treat facial and tooth pains) and the GB meridian in its external pathway crosses the region of the ear and face22.
It is also considered that the external TB meridian pathway, when climbing through the posterior shoulder, crosses points of the small intestine meridian (SI)22, being this important because in the pathway of these two meridians there are jaw elevator muscles and facial muscles, which are anatomic sec-tors afected in this clinical case (Figure 4).
Figure 4 – Anatomy of trigeminal and facial nerves location (black line) and their intersection with TB, SI and H meridians (dotted line).
he SI17 point (Tianrong), due to its location right below the jaw angle, in the anterior margin of the sternocleidomas-toid muscle, has helped promoting neck muscles relaxation and, for having energetic function and for harmonizing Qi circulation, it is indicated to treat deafness and tinnitus22. SI18 (Quanliao), with clinical application for painful facial disorders, is located inferior to the zygomatic arch, below the lateral angle of the eye, and point H36 (Zusanli) as a general energy regulating point22, to balance the center and, as a con-sequence, the whole body.
According to results, there has been improvement shown by VAS; after the sixth acupuncture session, patient had im-proved 95% and total tinnitus manifestation has imim-proved 100%, which may be physiologically and anatomically justi-ied because in the cranial-cervical complex, all structures are related. In case of the auditory system, it is located in the petrous portion of the temporal bone (crossed by GB me-ridian), which is related to the tensor and levator muscle of
velum and of the auditory tube (related to SI and TB merid-ian). When these structures are in permanent contraction due to emotional stress, they induce constant vasoconstriction of such muscles (lack of blood irrigation, which for the TCM is Xue deiciency), interfering with the entrance of air, thus un-balancing internal atmospheric pressure, which would cause tinnitus.
Emotionally, the indication of the presence of the emotional factor may be observed by the intense red color of the tip of the tongue, area corresponding to the heart meridian ac-cording to the tongue microsystem16. hrough the H7 point – Shenmen, which is the Door of the Spirit, it was possible to balance Yang Qi and Xin Qi of the heart as well as when the point of its coupled meridian SI 17 is used, because all senses depend on the heart, since the mind receives sensory perceptions.
he emotional is an important part of human beings, however very often it leaves its subjective aspect causing manifesta-tions in the physical body, relected in pathological signs and symptoms, indicative of the need for treatment. Acupuncture works in this level, since needle insertion, which produces a series of chemical reactions, stimulating peripheral nitric oxide and other substances release11, as well as by local va-sodilation, improving circulation of diferent luids (Xue). here are analgesic, muscle relaxant, sedative, anxiolytic, an-ti-inlammatory, immunity inducer and other efects which occur through neural, neuro-humoral and neurochemical mechanisms17.
CONCLUSION
In this clinical case, acupuncture has provided muscle relax-ation with beneits for masticatory muscles and middle ear muscles (tensor tympani), as well as for palate levator mus-cles, decreasing orofacial pain and tinnitus intensity.
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